| 1 | 1 | | |
|---|
| 2 | 2 | | |
|---|
| 3 | 3 | | |
|---|
| 4 | 4 | | |
|---|
| 5 | 5 | | 2023 -- H 5255 |
|---|
| 6 | 6 | | ======== |
|---|
| 7 | 7 | | LC000787 |
|---|
| 8 | 8 | | ======== |
|---|
| 9 | 9 | | S TATE OF RHODE IS LAND |
|---|
| 10 | 10 | | IN GENERAL ASSEMBLY |
|---|
| 11 | 11 | | JANUARY SESSION, A.D. 2023 |
|---|
| 12 | 12 | | ____________ |
|---|
| 13 | 13 | | |
|---|
| 14 | 14 | | A N A C T |
|---|
| 15 | 15 | | RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UT ILIZATION |
|---|
| 16 | 16 | | REVIEW ACT |
|---|
| 17 | 17 | | Introduced By: Representatives Edwards, Ackerman, Kazarian, Alzate, Potter, Bennett, |
|---|
| 18 | 18 | | Caldwell, Craven, Casey, and Casimiro |
|---|
| 19 | 19 | | Date Introduced: January 27, 2023 |
|---|
| 20 | 20 | | Referred To: House Health & Human Services |
|---|
| 21 | 21 | | |
|---|
| 22 | 22 | | |
|---|
| 23 | 23 | | It is enacted by the General Assembly as follows: |
|---|
| 24 | 24 | | SECTION 1. Chapter 27-18.9 of the General Laws entitled "Benefit Determination and 1 |
|---|
| 25 | 25 | | Utilization Review Act" is hereby amended by adding thereto the following section: 2 |
|---|
| 26 | 26 | | 27-18.9-16. Utilization review decisions. 3 |
|---|
| 27 | 27 | | (a) A utilization review decision shall not retrospectively deny coverage for health care 4 |
|---|
| 28 | 28 | | services provided to a covered person when prior approval has been obtained from the insurer or 5 |
|---|
| 29 | 29 | | its designee for those services, unless the approval was based upon fraudulent, materially 6 |
|---|
| 30 | 30 | | inaccurate, or misrepresented information submitted by the covered person, authorized person, or 7 |
|---|
| 31 | 31 | | the provider. 8 |
|---|
| 32 | 32 | | (b) For health benefit plans issued or renewed on or after the effective date of this section, 9 |
|---|
| 33 | 33 | | an insurer shall not require or conduct a prospective or concurrent review for a prescription 10 |
|---|
| 34 | 34 | | medicine: 11 |
|---|
| 35 | 35 | | (1) That is used in the treatment of alcohol or opioid use disorder; 12 |
|---|
| 36 | 36 | | (2) That contains Methadone, Buprenorphine or Naltrexone; or 13 |
|---|
| 37 | 37 | | (3) That was approved before the effective date of this section by the United States Food 14 |
|---|
| 38 | 38 | | and Drug Administration for the mitigation of opioid withdrawal symptoms. 15 |
|---|
| 39 | 39 | | (c) In conducting utilization reviews for Medicaid benefits, each Medicaid managed care 16 |
|---|
| 40 | 40 | | organization shall use the medical necessity criteria selected by the Rhode Island division of 17 |
|---|
| 41 | 41 | | insurance for making determinations of medical necessity and clinical appropriateness pursuant to 18 |
|---|
| 42 | 42 | | |
|---|
| 43 | 43 | | |
|---|
| 44 | 44 | | LC000787 - Page 2 of 3 |
|---|
| 45 | 45 | | the utilization review plan. 1 |
|---|
| 46 | 46 | | SECTION 2. This act shall take effect upon passage. 2 |
|---|
| 47 | 47 | | ======== |
|---|
| 48 | 48 | | LC000787 |
|---|
| 49 | 49 | | ======== |
|---|
| 50 | 50 | | |
|---|
| 51 | 51 | | |
|---|
| 52 | 52 | | LC000787 - Page 3 of 3 |
|---|
| 53 | 53 | | EXPLANATION |
|---|
| 54 | 54 | | BY THE LEGISLATIVE COUNCIL |
|---|
| 55 | 55 | | OF |
|---|
| 56 | 56 | | A N A C T |
|---|
| 57 | 57 | | RELATING TO INSURANCE -- BENEFIT DETERMINATION AND UTILIZATION |
|---|
| 58 | 58 | | REVIEW ACT |
|---|
| 59 | 59 | | *** |
|---|
| 60 | 60 | | This act would establish a prohibition on health care insurers from requiring or conducting 1 |
|---|
| 61 | 61 | | a review for prescription medicine that is used in the treatment of alcohol or opioid use disorder, 2 |
|---|
| 62 | 62 | | that contains Methadone, Burenorphine, or Naltrexone or that was approved for the mitigation of 3 |
|---|
| 63 | 63 | | opioid withdrawal symptoms. 4 |
|---|
| 64 | 64 | | This act would take effect upon passage. 5 |
|---|
| 65 | 65 | | ======== |
|---|
| 66 | 66 | | LC000787 |
|---|
| 67 | 67 | | ======== |
|---|